What is the definition of end stage renal disease? (ESRD)
“…irreversible damage to a person’s kidneys so severely affecting their ability to remove or adjust blood wastes that, to maintain life, he or she must have either dialysis, or a kidney transplant…”
What are the clinical features of advanced CKD?
Until CKD stage 4 or 5 - may be asymptomatic
Syndrome of advanced CKD is called uraemia
Uraemic syndrom can involve every organ system but the earliest and cardinal symptom is malaise and fatigue
When is RRT usually commenced?
When eGFR is less than 10 ml/min
or patient is symptomatic of uraemia
What are the types of renal replacement therapy?
Haemodialysis (home or hospital)
Peritoneal dialysis (CAPD - continuous ambulatory peritoneal dialysis vs intermittent peritoneal dialysis)
Conservative kidney management
What are the two mechanisms of solute movement in dialysis?
Ultrafiltration - pressure filtration
What are the pre-requisites for dialysis?
Semipermeable membrane (artifical kidney in haemodialysis or peritoneal membrane)
Adequate blood exposure to the membrane (extracorporeal blood in haemodialysis, mesenteric circulation in PD)
Dialysis Access vascular in haemodialysis, peritoneal in PD
Anticoagulation in hemodialysis
What are the different access points for haemodialysis?
–AV prosthetic graft
–Tunnelled venous catheter
–Temporary venous catheter
Look at the movement of solutes
Note that creatinine and urea are both completely removed
What are the restrictions for dialysis patients?
Fluid - dictated by residual urine output
Dietary restriction - potassium, phosphate, sodium
What is the mechanism of peritoneal dialysis?
Balanced solution is instilled into the peritoneal cavity using the peritoneal mesothelium as a dialysis membrane
After a dwell time the fluid is drained out and fresh dialysate is instilled
What are the mechanisms of peritoneal dialysis?
Continuous ambulatory peritoneal dialysis (CAPD)
Automated peritoneal dialysis (APD)
Describe the peritoneal dialysis fluids
Dialysate contains a balanced concentration of electrolytes
Glucose - most common osmotic agent for ultrafiltration of fluid
•The peritoneal transport characteristics can vary from high transporter to low transporter
–Dwell times can be adjusted according to transport characteristics
What are the comlpications of peritoneal dialysis?
Exit site infection
PD peritonitis - gram positive - skin contaminant
Gram negative - bowel origin
mixed - suspect complicated peritonitis - e.g perforation
Encapsulating peritoneal sclerosis
- Tube malfunction, abdominal wall herniae
What are the indicatinos for dialysis in ESRD? - end stage renal disease
•Advanced uraemia, (GFR 5-10 ml/min)
•Severe acidosis (bicarbonate <10 mmol/l)
•Treatment resistant hyperkalaemia (K >6.5 mmol/l)
•Treatment resistant fluid overload
•Nephrologist’s clinical judgment is important
What is the difference in fluid restriction between haemodialysis and peritoneal dialysis?
Haemodialysis - restricted to 500 - 800 ml/24 hours intake allowed = urine output and insensible loss
Peritoneal dialysis - more liberal intake as continuous ultrafiltration is often achieved
What are dialysis related drugs?
–IV iron supplements
•Renal Bone Disease
–Activated Vitamin D (eg calcitriol)
–Phosphate binders with meals (CaCo3)
•Water soluble vitamins
What are the complications of haemodialysis?
Cardiovascular problems: Intradialytic hypotension and cramps, arrythmias
Coagulation: Clotting of vascular access, heparin related problems
Other: Allergic reactions to dialysers and tubing, catastrophic dialysis accidents (rare)
Patients on (any type) of dialysis have increased morbidity and mortality